There are several reliable methods for detecting Helicobacter pylori (H, pylori) infection, but all of them have both advantages and disadvantages. In this study, we investigated intragastric ammonia levels (IALs) as a screening method for H. pylori infection. This test was performed on 126 patients referred for routine endoscopy, and results of IALs were compared with those from culture and histology. All patients whose IALs are over 5.0mg/dl showed H, pylori positive, and its sensitivity of H, pylori detection was 87.6% and specificity was 100% when more than 5.0mg/dl of IALs assumed H. pylori positive. H. pylori positive patients whose IALs were below 5.0mg/dl showed high ratio of both aged patients and intestinal metaplasia in histology, while H. pylori negative patients had high ratio of younger patients and those histological findings showed no or mild intestinal metaplasia. The measuring of IALs is considered to be a simple, cheap, rapid, and non-radioactive test for the screening of H. pylori infection.

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I have amended the peritoneoscopic code number system for chronic liver diseases reported by us in 1971 with some addenda. "Tens" column of the three-figure code : a borderline of the diameter of cirrhotic nodules was set at 5mm, code number 10 was defined as diameter being less than 5 mm, and code number 20 being 5mm or more. This is because code number 10 was supposed to include cases with liver diseases of both viral and alcoholic etiologies, and code number 20 of other etiologies. According to the development of peritoneoscopy as an aid in intravenous injection of Indocyanine Green (ICG), patches can be easily differentiated from interstitial tissue, and cases with wide intervals between patches were included into code number 30. In this case, topical histology of intervals showed chronic hepatitis but whole histology showed chronic hepatitis with liver cirrhosis. From the study on peritoneoscopic findings in chronic hepatitis, type C, small yellowish white spots indicative of follicular formation in the Glisson's sheath were included in code number 1, and reddish markings in chronic hepatitis, type C, in code number 4. Furthermore, gutter-or-trench shaped depressions following above reddish marking were newly defined as code number 5.

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Endoscopic ultrasonography (EUS) is good in diagnosing submucosal structure of the gastrointestinal tract.We previously reported the "malignant sign (MS)" of EUS findings, combination of the internal echo pattern and the tumor size, for the differentiation of malignant SMTs from retrospective analysis. In this study, we analysed EUS finding of newly diagnosed SMT patients prospectively to compare with the histological findings. EUS was performed in 20 patients with SMTs, and MS was judged. MS was assigned to 1) tumor larger than 20mm with intermediate or mixed irregular echo pattern, or 2) tumor larger than 40mm with hypoechoic pattern. Eleven patients had MS. Eight of the 11 MS SMTs were malignant in histological diagnosis (7 leiomyosarcomas and 1 leiomyoblastoma), and three were benign (leiomyoma, neurinoma and abberent pancreas). Sensitivity of MS in the prospective diagnosis was 100% and the specificity was 75%. MS in EUS derived from the combination of internal echo pattern and tumor size was highly sensitive and specific in this prospective study as in retrospective study. We conclude that MS was clinically useful in differentiation of malignant SMTs from benign SMTs.

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Aphthoid ulcer, known as an early lesion of Crohn's disease, and lymphoid hyperplasia (LH) of the colon were studied with a magnifying colonoscopy in Crohn's disease patients in terms of their incidence, distribution and changes with enteral nutrition (EN) therapy. With magnifying colonoscopy : FUJINON EVC-HM (Maximum magnification×14, focus 8mm), total colonoscopy was performed in 28 Crohn's patients. The incidence and distribution of aphtha and LH were studied as well as changes of those before and after EN therapy. In addition, 40 serial sections of biopsy specimens were used to detect granuloma/granulomatous lesions. The results were as follows; 1. Aphtha and LH were observed in 14 (50.0%) and 12 (44.1%) of 28 Crohn's patients, respectively. 2. On serial sections of specimens biopsied from aphtha and LH, granuloma/granulomatous lesions were his-tologically revealed in 10 (71.4%) of 14 aphthas and 5 (41.7%) of 12 LH. 3. After EN therapy, aphtha disappeared or decreased in number in 6 (75%) of 8 patients, but LH increased in number or progressed to aphtha in 2 (40%) of 5 patients. These results suggested that aphtha and LH observed by magnifying colonoscopy appear to be early lesions of Crohn's disease, and EN therapy was effective to these lesions and may inhibit progression of Crohn's disease.

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A 2-channels electronic video-colonoscope (CF-2T200 I) has newly been developed by Olympus Co. for a better colonoscopic instrumentation. The scope has two instrument channels (left channel with 2.8mm and right channel with 3.7 mm in diameter respectively) which an ultrasonic probe with 3.4 mm in diameter can intubate easily. This new scope was applied 215 times of examination in 117 patients with colonic diseases (46 times for observation with biopsy, 30 times for endoscopic ultrasonography with an ultrasonic probe and 139 times for endoscopic electrosurgical resection). By using this instrument, total colonoscopy was successful in all of 92 attempted cases and endoscopic ultrasonography was successful in 30 cases without any trouble. Endoscopic polypectomy and mucosal resection were also easily manipulated by the combined use of a grasping forceps and a polypectomy snare that could pass through the both channels of the scope. Based on these results, we can evaluate that this new scope is considerably valuable as a colonoscopic instrumentation.

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We report a case of esophageal hemangioma which was well treated by administration of Etanolamine Oleate (EO) and Cyanoacrylate (CA). A 48-year-old male who was carried out the endoscopy because a protruding lesion of the esophagus was pointed out by medical examination, and he was admitted because of growing of it endoscopically in next year. Two nodular protruding lesions which were blue calor and redness on the surface were endoscopically observed. These 20mm and 15mm in size lesions at 28cm and 30cm from the incisor tooth after admission were easily depressed by pressure of the forceps. Endoscopic injection sclerotherapy was performed for these cases which was suspected hemangioma. After aspiration of the blood by using 23-G puncture needle, EO was infused, and needle was pulled out by following infusion of CA. Endoscopic findings showed the exposure of CA in 1 week and dropout of it and improvement of lesions in 2 weeks respectively. The blood gas analysis collected from tumor was as same as that in the arterial blood. This method was considered to be a new endoscopical therapy in the esophageal hemangioma. This case was supposed to be a Blue Rubber Bleb Nevus Syndrome associated with hemangioma in the digestive tract and skin.

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A 60 year-old female, who had maintained by chronic hemodialysis for five years, was admitted to our hospital because of severe anemia. Upper gastrointestinal endoscopy before admission revealed bleeding hemorrhage in the gastric antrum. Follow-up endoscopy on admission showed longitudinal stripes consisted of many red spots in the distal part of the gastric antrum, and the endoscopic view of which resembled the stripes of a watermelon. In addition, hypermobility of the gastric antrum could be markedly confirmed by precise observation during endoscopy. The possibility of bleeding from the gastric antrum was suggested by angiography and RI scincigraphy. Other investigations, including barium examination through the small intestine and colonoscopy could not detect any other source of gastrointestinal bleeding. Because the gastrointestinal bleeding was uncontrolable and anemia progressed in spite of intensive medical therapy, she was surgically treated by gastric antrectomy and Billroth II anastomosis. Histological finding of the resected specimen revealed fibromuscular hyperplasia in the lamina propria, fibrin thrombi of the true capillaries, and dilated blood vessels in both the lamina propria and the submucosa. In consideration of these endoscopic and histologic findings, we diagnosed this case as antral vascular ectasia. In addition, the endoscopic observation of hypermobility in the gastric antrum may have played an important role on the pathogenesis of vascular ectasia in our case.

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A 44-year-old man was found to have an abnormality in the gastric antrum on mass examination for adult diseases in September 1991. The patient visited to our department for the more detailed examination on November 1, and was admitted on November 28. Examination by x-ray and endoscopic examination revealed a submucosal tumor of approximately 3cm in size. The surface of the tumor was slightly uneven and was associated with a bridging fold. Endoscopic ultrasonography revealed that the tumor extended from the submucosal layer to the proper muscle layer, and appeared to be continuous with the proper muscle layer. The inside of the tumor was almost homogeneous and showed a slightly higher echoic level than the proper muscle layer, resembling the findings of leiomyoma. The patient underwent partial resection of the tumor at the department of surgery of our hospital on January 10. The specimen was 32×22×18mm in size, and histological examination revealed that the tumor was a glomus tumor in the submucosal and proper muscle layers.

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A 75-year-old man without symptom visited our hospital for examination of the upper gastrointestinal tract. Upper GI series and endoscopic examination revealed three elevated lesions (Yamada type II, type IV, type I) with central depression in the descending part of the duodenum. Histological examination of biopsy specimens obtained from the central depression of the first lesion disclosed heterotopic gastric mucosa (HGM) and carcinoid. Surgical resection of all tumors was performed, and there was no evidence of metastases. Resected specimens measured 8×8mm, 7×7×13mm, and 3×3mm in size. All of elevated lesions consisted of HGM and only the Yamada type II lesion had carcinoid. HGM is rare in the descending part of the duodenum. From the review of Japanese literatures, this case is the first report in Japan of HGM associated with carcinoid in the duodenum.

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Our case is a 73 year-old man. Barium enema and colonoscopy showed a nodular tumor like ha around the appendiceal orifice. Histologically, biopy specimens revealed a tubular adenoma with severe atypia. Ileocecal resection was done. Macroscopically, the lesion was a well demarcated f alt tumor 35×60mm in size with nodular-aggregated surface around the appendiceal orifice. Histological examination revealed carcinoma in adenoma. In microangiography, the stalk vessels was noted in the nodular area, and the vascular patterns in the flat elevated lesion were similar to the mucosal vessels. This is a rare case in the location of the tumor, and the multiple hyperplastic polyps in the stomach were associated.

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We reported the findings of endoscopic ultrasonography (EUS) for three cases with gastric inflammatory fibroid polyp (IFP). Case 1; 63-year old female had a complaint of upper abdominal pain. Upper gastrointestinal endoscopy revealed a protruding lesion 10mm in diameter in the antrum of the stomach. EUS showed an almost uniform hypoe-choic mass in the third layer and thickening of the second layer with intact fourth layer of the gastric wall. Case 2;79-year old female had also a complaint of upper abdominal pain. Endoscopic examination showed a smooth elevated lesion 7mm in diameter in the antrum of the stomach. EUS revealed a hypoechoic mass in the third layer. Case 3;45-year old male suffered from liver cirrhosis and esophageal varices. Endoscopic examination showed a slightly reddish elevated lesion 10mm in diameter in the corpus of the stomach. EUS also revealed an almost homogeneous hypoechoic mass in the third layer. In three cases, these lesions were demonstrated as hypoechoic tumors in the third layer of the gastric wall by EUS. Endoscopic polypectomy was performed for 3 lesions and were diagnosed as IFP histologically. The lesions were confirmed histologically to exist in the third layer of the gastric wall as expected by the findings of EUS.

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A 32 year old female was admitted to our hospital complaining of left lower abdominal pain. Barium enema-study and Colonoscopic examination showed a walnut sized thinly coated granular surfaced elevated lesion with partial reddening in the sigmoid colen. Biopsy studies gave no worthy information. On the 2nd and 5th hospital day, intussuscep-tion had occurred prolapse of the tumor from the anus was recognized. Submucosel tumor was suspected, and sigmoidectomy was performed. Histological finding showed a inflam-matory fibroid polyp. Fibromuscular obliteration was recognized at the surrounding mucosa of the base of the polyp. Only 7 cases was reported in the literatures in Japan including our case.

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A 62-year-old man was pointed out positive fecal occult blood in screening test with no subjective symptoms in 1988 and in 1989. Barium enema and colonoscopy examined by a familial doctor revealed a pedunculated polyp of the sigmoid colon. The biopsy specimen revealed no malignancy pathohistologically. We performed the endoscopic polypectomy. The pedunculated polyp removed by endoscopic polypectomy showed the reddish head 30 × 15 × 15 mm in size that was present on a white stalk with mucinous tubercle mucin and it was confirmed pathohistologically as mucinous adenocarcinoma invading to submucosa. Most of reported cases of mucinous adenocarcinoma in the colon were advanced cancer, but our case was a early cancer. To the best our knowledge, early mucinous adenocarcinoma of the colon like this cases has rarely been reported and it was supposed to be a important case.

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A 38-year-old woman, who received surgical operations for panperitonitis developed with unknown cause and for ovarial dermoid cysts 14 and 10 years ago, respectively, was admitted to our hospital requesting further examination of multiple abdominal tumors pointed out elsewhere. Plain X-ray, US, CT and MRI pictures demonstrated, in the abdominal lumen, multiple tumors, 1 to 7cm in size, with calcified wall and soft contents suggesting fat. On laparoscopy, the tumors with whitish thin wall were seen in the abdominal lumen sticking on the lower surface of the liver, the greater omentum and peritoneum. Laparotomy was performed and 36 abdominal tumors were removed in total. Histologically, the surface wall of tumors was composed of vitreous substances partially calcified and the content in most tumors was fat. Although there were no components derived from the germ layers in the tumor content, the tumors regarded as those dis-seminated from ovarian dermoid cysts detected 14 years ago when she had an episode of panperitonitis, on the basis of the clinical features and her past history. There were 4 previous reports of peritoneal multiple dermoid cysts of ovary comprised of fat.

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A 72-year-old man visited our department with the chief complaint of jaundice. Under the diagnosis of obstructive jaundice, percutaneous transhepatic biliary drainage (PTCD) and percutaneous transhepatic cholangioscopy (PTCS) were performed. Although primary sclerosing cholangitis was suspected, the complication of malignant tumor was also considered. Formation of an internal fistula for PTCD and endoscopic retrograde biliary drainage were impossible because of narrowing of the hepatic duct in the porta hepatis and narrowing of the common bile duct. Percutaneous endoscopic gastrostomy was performed to reduce jaundice by forming an internal fistula according to the method of Shike et al. From the fistula, a catheter 5 mm in diameter was inserted percutaneously through the stomach into the duodenum under endoscopic observation, and the other end of the catheter was extracorporeally anastomosed to the PTCD catheter for external biliary duodenal drainage. When the catheter was placed in an appropriate position in the duodenum, favorable drainage was obtained. Treatment by external biliary duodenal drainage seems to be a useful method of forming an internal fistula. It enables favorable reduction in jaundice by forming an internal fistula, even on an outpatient basis, without causing any severe complications.

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A 41 year old woman with pigmentation of the lip and the fingers was admitted to our institution. Gastrointestinal examination showed polyposis in the small intestine and the colon. We resected 23 polyps of the colon endoscopically. Histological findings of the pedunculated polyp, 50mm in size which were endospically taken from the recto-sigmoid colon, showed well-differentiated adenocartinoma. Forty-six small intestinal polyps were endoscopically and surgically polypectomized. We resected 67 of 69 polyps endoscopically. There were few reports concerning endoscopic polypectomy for many polyps. At present, there were many case reports about high malignant potential of Peuz-Jeghers syndrome. From the experience of this case, it is suggested that long term follow-up observation is important for the early detection of malignant lesion and endoscopic polypectomy is useful for the treatment in the patients with Peutz-Jeghers syndrome.

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A 33-year-old man with chronic hepatitis C showed marked changes on the liver surface after interferon therapy. The first peritoneoscopic diagnosis was code number 314, 2 by Shimada's classification, and histologic finding of the specimen taken from the liver revealed chronic aggressive hepatitis 2B with submassive hepatic necrosis. Six million units of alpha-interferon were administered subcutaneously three times a week for 6 months. The second peritoneoscopic diagnosis after a year of the therapy was code number 311, 6, and histologic finding showed liver fibrosis. Disappearance of reddish markings and appearance of white markings were observed on the liver in a patient with complete response by interferon therapy.

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Laparoscopical and histological findings of the liver were examined in two patients with both congenital hepatic fibrosis and Caroli disease. Patient 1 was 25 years old female, and was referred to our department because of pancytepenia which was found at her first delivery. Patient 2 was 41 years old female, and visited our hospital because of fever and right hypochondralgia. Cholagiography showed multiple cystic dilatations of intrahepatic bile duct which indicated Caroli disease in both patient. Histological examination revealed wide fibrosis of portal area, increased number of dilated bile duct and decreased number of portal vein in both patient, indicating congenital hepatic fibrosis. Wide and discrete whitish marking which reflect marked fibrosis of portal area was observed in reticular or tree branch pattern laparoscopically. This whitish marking was supposed to be a charac-teristic laparoscopical finding in patients with congenital hepatic fibrosis.

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A newly designed transparent plastic cap fitted to the tip of colonoscope was evaluated regarding to insertion of scope, visual field, polypectomy and mucosectomy. A transparent plastic cap has a 17-mm in outer diameter, l5-mm in inner diameter and 10-mm in length and is easily attached to the tip of the colonoscope. This method attained a good continuous visual field during insertion of scope and the lens of scope never contacted to the surface of mucosa. We could recognize easily the continuity of lumen through the wall of this cap at the turning point. Blind part of mucosa behind the fold of colon could be well observed by the oppresion of the cap. During mucosectomy after local injection of saline solution the target mucosa was sucked inside the cap and snared under a full endoscopic suction. We call this procedure EMRC (Endoscopic mucosal resection using a cap-fitted endoscope). We conclude that colonoscopy wearing a transparent cap is a very useful procedure not only as a diagnostic procedure but a therapeutic measure.

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In cases of jaundice due to hepatic hilar bile duct stenosis, drainage of both the right and the left hepatic bile duct is required. However, selective insertion of stents by EBD has not been a treatment of choice. We attempted selective insertion of stents by EBD in inoperable cases of hepatic hilar bile duct stenosis, and the results are herein reported EBD was attempted in 19 cases, 11 cases of bile duct cancer and 8 cases of gallbladder cancer. The success rate was 73.7% and drainage was satisfactory. Successful insertion of stents had no relation with either the original disease or the length of stenosis. There was a tendency for the success rate to be low in cases of complete separation of the right and the left bile duct. We would like to stress that selective stent insertion by EBD should be considered as a possible alternative treatment in such cases.

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